Applying to multiple surgical fellowships

[AlphaMed]

---

Members don't see this ad.

Does anyone have a clear idea whether this is possible with certain fellowships? For example surg onc/transplant are both with NRMP and HPB/Minimally invasive are on the fellowship council. The rank list and matching dates for both organizations are identical. Do they do this purposefully to limit applying to multiple fellowships?

As someone who is interested in hepatobilliary surgery there are multiple ways to get there with surgonc/hpb/transplant fellowships (all with their pros and cons). It just seems as if it may not be possible to apply to all three in one year, am I missing something?

 

[vhawk]

This used to be somewhat doable, in the sense that you could apply to SSO and HPB and then withdraw from SSO if you matched into HPB (but not the other way around without sitting out a year) but I havent looked recently at the timing of the interview dates, match, withdrawal dates etc to see if it is. Ultimately the thing driving the decision making is that match decisions are binding in the same way that residency match decisions are, so unless the date to withdraw from one match is after the match date for the one you "want more," it will not be possible.

I also dont think its really all that advisable, as although it is true that for the most part, SSO programs and HPB programs are at different institutions (MSK, Toronto and I think MDA are the exceptions to this) its a small world and everyone knows everyone and it looks bad.

If you would like more information on the pros and cons of each approach I would be happy to talk about that, and there are a few videos posted somewhere of lectures given by faculty in each discipline about the topic. It was a major topic of interest for a few years at the various national meetings and so a lot was written about it.

In summary, one-liners for each approach:

HPB: Ideal pathway if you already have a job lined up that specifically just needs you to gain some experience in complex or MIS HPB cases, less than ideal if your goal is a major academic surgonc/HPB job (though not impossible, as I can attest), middle of the road competitiveness (more competitive than transplant, less than surg onc)

Surg Onc: most competitive pathway, ideal if you want to do academic surgical oncology, also ideal if you want to do broad-based community or PP surgical oncology including breast, colons, melanoma, HPB etc

Transplant: Least competitive (though still competitive at the top programs) and the experience in HPB is EXTREMELY variable so approach with caution if the plan is to do HPB for a living, but it opens up the fallback option of doing kidneys and access and the job opportunities in academics are definitely greater in quantity, if not in quality.

 

[vhawk]

No, it would neither be possible nor a good idea to try and apply to all three, or even two of the three.

You should talk to mentors and try to help figure out which path is right for you.

There is a lot of discussion about the pros and cons of each route. Some people (mainly surg onc people) think the standalone HPB fellowships are not going to exist much longer. While that is debatable, it’s definitely true that m the number of slots has dropped and several programs have closed their fellowship. I know of at least one more that is closing next year.

The difference between a transplant fellowship and a CGSO fellowship is huge and you should be able to decide which of these is more appealing to you.

I'm interested to hear which program is closing, I know of one of them that is converting to SSO (I do not think this is a secret any longer, hope I'm not wrong) but overall I dont think that the number of spots has changed dramatically in the last 5 or 6 years. The FC website lists 17 programs which is actually I think 1 or 2 more than there was a few years ago.

 

[klmnop]

This used to be somewhat doable, in the sense that you could apply to SSO and HPB and then withdraw from SSO if you matched into HPB (but not the other way around without sitting out a year) but I havent looked recently at the timing of the interview dates, match, withdrawal dates etc to see if it is. Ultimately the thing driving the decision making is that match decisions are binding in the same way that residency match decisions are, so unless the date to withdraw from one match is after the match date for the one you "want more," it will not be possible.

I also dont think its really all that advisable, as although it is true that for the most part, SSO programs and HPB programs are at different institutions (MSK, Toronto and I think MDA are the exceptions to this) its a small world and everyone knows everyone and it looks bad.

If you would like more information on the pros and cons of each approach I would be happy to talk about that, and there are a few videos posted somewhere of lectures given by faculty in each discipline about the topic. It was a major topic of interest for a few years at the various national meetings and so a lot was written about it.

In summary, one-liners for each approach:

HPB: Ideal pathway if you already have a job lined up that specifically just needs you to gain some experience in complex or MIS HPB cases, less than ideal if your goal is a major academic surgonc/HPB job (though not impossible, as I can attest), middle of the road competitiveness (more competitive than transplant, less than surg onc)

Surg Onc: most competitive pathway, ideal if you want to do academic surgical oncology, also ideal if you want to do broad-based community or PP surgical oncology including breast, colons, melanoma, HPB etc

Transplant: Least competitive (though still competitive at the top programs) and the experience in HPB is EXTREMELY variable so approach with caution if the plan is to do HPB for a living, but it opens up the fallback option of doing kidneys and access and the job opportunities in academics are definitely greater in quantity, if not in quality.

As someone who works in an institution with poor mentorship in this area, could you
1) expand on the usefulness of the HPB fellowship and what kind of jobs you would be getting
2) give a vague example of the "average" CV for each of the three pathways as I feel I am literally in the dark about qualifications and competitiveness.

Edit: Also would love to hear more about pro's and cons
My ill-informed thought process coming from a DO residency is:

1) SurgOnc is ideal but without significant research or ACGME background would take a miracle.
2) HPB provides a good basic intensive Liver/Panc surgery background that you can feel comfortable taking into private practice. The competitiveness and usefullness I have no idea about. Also no idea about if anyone will hire you to do HPB afterward.
3) Transplant is easiest to get into to end up doing HPB, however diagnosing and treating transplant patients is sometimes like doing Mars medicine compared to general surgery.

I'm kind of like OP. I really am interested in HPB surgeries, didnt get a good background in it, but dont want it to be a waste of time and dont know which route is ideal.

 

[vhawk]

The biggest factor is that we are training too many people to do HPB for too few jobs, at least in major academic centers. HPB fellowships are graduating 15 or so people each year, SSO fellowships are graduating 40-some (though obviously not all of these are interested in doing HPB) and there are probably about 10-15 jobs per year in academic centers doing primarily HPB. So those programs basically have their pick among the top grads, or from among established surgeons if thats what they are looking for. So in order to stand out and get these jobs, you have to demonstrate academic success. SSO programs select more stringently for that, and on average their applicants are just "better" and so they have a distinct leg up on those jobs. Among the HPB fellowship graduates last year, I think maybe 2 or 3 of them ended up with academic HPB jobs, and the rest either took a hybrid type job, a private practice type job, or went into another fellowship/did something other than HPB.

HPB fellowships have tried to sort of establish a niche, and one area is doing minimally invasive complext HPB cases, which some old-school surg onc programs had in the past lagged behind in. This is becoming less the case, making the case for doing an HPB fellowship less and less obvious.

As it stands, I would say that the biggest advantage to doing an HPB fellowship over an SSO one is that they are either 1 or 2 years, as opposed to 2 or 3 years, and that you do a lot less non-HPB stuff. Other than that, SSO programs are generally going to open more doors, etc. So like I said, if you have a specific job lined up and your main goal is to simply get the exposure and experience doing complex HPB cases and MIS/robotic HPB to bring back to your program or to bring to your job, HPB fellowship is the best way to get that. If you want to become a bigshot big name academic HPB surgeon, SSO is better, though HPB does not mean its IMPOSSIBLE.

SSO fellowships are more competitive, but HPB fellowships arent non-competitive either.

 

[klmnop]

Thank you for the reply.
Correct me if I'm wrong but I would argue that the vast majority of SurgOnc graduates are somewhere random in private practice with a large minority in academic centers without fellowships and a minority in academic centers with them.

If I understand your message, unless you are stellar or lucky as an HPB trained fellow your best bet is to find a niche in an underrepresented area so HPB cases are funneled to you, rather than an Onc service at a large academic center.

Personally I don't need to be a big shot academic surgeon. It would make me feel good but not absolutely necessary.

Do you think it's feasible to have a 'mainly' HPB practice without joining the large academic centers or is this not happening?

Sent from my Pixel XL using Tapatalk

 

[klmnop]

That’s just not a very realistic plan.

There isn’t enough volume of those cases to expect to be able to build a practice in a smaller area on your own. You need a referral base and you need other skilled subspecialists (med onc, rad onc, IR, and advanced endoscopists all critical to the care of HPB patients).

And don’t forget that HPB is the original home of the volume/outcomes research. So if you’re being honest with yourself - if you’re a low volume pancreas surgeon you really shouldn’t be doing those cases.
—

IMHO if you haven gotten adequate exposure to these cases in residency I don’t really understand how you can even think to sign up for a fellowship like HPB or transplant.

So based on the initial comment that virtually no HPB fellow will end up in a large academic center. As well as what you are saying that the volume does not exist outside these centers... would you conclude that the HPB fellowship is useless?

And if not, who is it for?

Also, do people actually do transplant fellowships and not practice transplant Surgery, if so what do they do and did the transplant fellowship actually provide any benefit?

As to your last comment, with absolutely no ill will intended by the following: my perspective is that fellowship is for further refining skills that weren't necessarily heavily focused on in your general surgery residency, largely because they are super specialized. Your particular residency may have had a lot of liver resections but this is hardly a staple of GS training currently. Further, just because your program as a resident doesn't do a lot of robotic procedures does not mean you shouldn't go out and do an MIS fellowship to get more exposure so you can succeed in that.

 

[klmnop]

Alas I apologize for getting side tracked.

Sent from my Pixel XL using Tapatalk

 

[klmnop]

I understand better now, appreciate it.

The academic reference was responding to vhawk's comment.

Sent from my Pixel XL using Tapatalk

 

[vhawk]

Thank you for the reply.
Correct me if I'm wrong but I would argue that the vast majority of SurgOnc graduates are somewhere random in private practice with a large minority in academic centers without fellowships and a minority in academic centers with them.

If I understand your message, unless you are stellar or lucky as an HPB trained fellow your best bet is to find a niche in an underrepresented area so HPB cases are funneled to you, rather than an Onc service at a large academic center.

Personally I don't need to be a big shot academic surgeon. It would make me feel good but not absolutely necessary.

Do you think it's feasible to have a 'mainly' HPB practice without joining the large academic centers or is this not happening?

Sent from my Pixel XL using Tapatalk

I think it is definitely possible, certainly right now and probably going forward. There is sort of a low-level push to start funnelling complex cases such as major HPB cases to a smaller number of high volume centers (similar to Canada for example) but if this ever does really happen it will be a slow process. There are plenty of people in private practice doing "mainly" HPB (depending on how you define that but anywhere from 30-100%) and plenty in sort of hybrid style programs. There are pros and cons to that approach but you definitely dont HAVE to join a major academic center.

I dont really think its true that the majority of people doing HPB at major academic centers do not have surg onc fellowship training. Maybe 10 years ago but not now.

Yes I do think that it is challenging trying to compete for good academic HPB/onc jobs as an HPB fellow, though obviously not impossible. You are at a disadvantage because for the most part the people who are doing the hiring are surg onc trained, SSO is board certified, and to be frankly honest, the SSO candidates are probably just better on average.

 

[vhawk]

So based on the initial comment that virtually no HPB fellow will end up in a large academic center. As well as what you are saying that the volume does not exist outside these centers... would you conclude that the HPB fellowship is useless?

I did an HPB fellowship. I have an academic HPB/oncology job. It isnt impossible. But its challenging. I think 3 people who finished my year are in truly academic jobs, and a few more are in sort of hybrid jobs...but that could certainly partly be due to their own preferences. Academic jobs are definitely not for everyone.

And if not, who is it for?

Like I said before, you can do whatever you want, but I think the BEST reason to do an HPB fellowship is if you already have a specific job that you have either accepted or are likely to accept and you have discussed with them their specific need, and they just need someone to go out and get some experiecne doing, for example, robotic liver resections and RFA and robotic distal pancs, or something like that. Again, that wasnt me, so there are other routes, but in my experience that is the BEST reason to do an HPB fellowship.

Also, do people actually do transplant fellowships and not practice transplant Surgery, if so what do they do and did the transplant fellowship actually provide any benefit?

Transplant fellowships are widely variable, but they do suffer from some of the same job market issues as HPB/Surg Onc grads do. There arent that many liver txp jobs out there. There are a lot of kidney/access jobs. The advice that everyone always gives is, think about if you ended up with a 50% HPB job....what would you want the other 50% to be? If you would want it to be general surgery, then do HPB. If you would want it to be general surg onc stuff like breast or colons, do SSO. If you would want it to be kidney txps or access, do transplant. Thats very simplified and not entirely accurate but its a cliched way of thinking about it.

As to your last comment, with absolutely no ill will intended by the following: my perspective is that fellowship is for further refining skills that weren't necessarily heavily focused on in your general surgery residency, largely because they are super specialized. Your particular residency may have had a lot of liver resections but this is hardly a staple of GS training currently. Further, just because your program as a resident doesn't do a lot of robotic procedures does not mean you shouldn't go out and do an MIS fellowship to get more exposure so you can succeed in that.

I think his point was more that you dont really know what to expect, and you dont have great mentorship, so you might be making a mistake that will have long-term ramifications. I dont strongly agree or disagree with him.

 

[mousedoc1]

Hi i was hoping if someone could provide information on HPB interview dates - we have plans to travel out of the country for the early part of january . the SSO publishes its calendar for interview slots annually. is there a similar resource out there for hpb fellowships?
Thanks

 

[mousedoc1]

I don’t know of any firm dates but given that January is before the application deadline I would strongly suspect you will be fine

Thank you.

 

[klmnop]

Does anyone have a clear idea whether this is possible with certain fellowships? For example surg onc/transplant are both with NRMP and HPB/Minimally invasive are on the fellowship council. The rank list and matching dates for both organizations are identical. Do they do this purposefully to limit applying to multiple fellowships?

As someone who is interested in hepatobilliary surgery there are multiple ways to get there with surgonc/hpb/transplant fellowships (all with their pros and cons). It just seems as if it may not be possible to apply to all three in one year, am I missing something?

Per the Fellowship Council FAQ:

CAN I PARTICIPATE IN MULTIPLE MATCHING PROCESSES?

Applicants may apply and interview in multiple matching process. However, applicants may only certify a rank order list for one matching process which have concurrent rank order deadlines/announcement of fellowship matches dates. Applicants who accept a position through another national matching process or by agreement outside the Fellowship Council matching process must withdraw PRIOR to the Fellowship Council rank order list deadline. Failure to do so is a violation of the Fellowship Council Matching Service Participation Agreement (FCMSPA), which all applicants agree to upon signing onto the matching process site. The violation will be investigated by the Fellowship Council. Applicants who elect to participate in the Fellowship Council matching process and certify a rank order list are prohibited from accepting a position through any other national matching service or by agreement outside the matching process after the rank order list deadline. For additional information, visit the Matching Process Information page. For additional information on the Violations Policy, visit the Matching Process Rules and Regulations page.

 

[droliver]

From a practical perspective if you want to do purely HPB surgery practice in the future, you’re going to have to carve out a bigger niche then the old JoHn Cameron model of just doing whipples and liver resections to pay the bills.

You’ll have to be able to do robotic pancreas and hepatic surgery. You’re going to need to learn therapeutic ERCP and endoscopic ultrasound, and you’re going to need to treat pancreatitis patients. Without capturing that full range of services. There just isn’t going to be enough business to churn the wheel in such a narrow field in most settings. The adoption of ERCP into everyday by traditional HBP specialists is probably the single biggest thing you can day to expand your practice I’d submit. The 3 guys I know that do this are doing hundreds of ERCP cases a year and get referrals from all over just for the benign stuff (CBd stones, strictures, pancreatitis) in addition to the cancer cancers.

 

[vhawk]

The problem with that is that if your goal is to practice in an academic setting, the opportunity for you to actually do ERCP and advanced endoscopy can be severely limited. Not everywhere (at my institution there is one surgeon who does advanced endoscopy and some ERCP) but in many if not most places. In private practice I generally agree, its a great way to build a practice, add on RVUs, and accumulate panc stuff, but even there, it depends somewhat on your community. Ultimately it may be a turf war and you will have to decide if the ERCPs are worth the decrease in referrals from upset GI docs. If you are the only game in town, less of a concern.

 

[boogaaloo]

No, it would neither be possible nor a good idea to try and apply to all three, or even two of the three.

Why do you say that?

 

[thedrjojo]

Don't do a Transplant fellowship unless you want to live, eat, breath, sleep Transplant. If you can't get excited for a 2am donor then the liver to follow to then have to do it all over again by the time that finishes then don't do it. If you aren't excited about that you will not survive a Transplant fellowship just to do hpb cases.

 

[TypeADissection]

Don't do a Transplant fellowship unless you want to live, eat, breath, sleep Transplant. If you can't get excited for a 2am donor then the liver to follow to then have to do it all over again by the time that finishes then don't do it. If you aren't excited about that you will not survive a Transplant fellowship just to do hpb cases.

If general surgery is a religion, then transplant surgery is a cult. Those dudes and dudettes get so amped for this stuff. Definitely not something you just dabble in, you either drink the Kool-Aid or stay away completely.

 

[boogaaloo]

If general surgery is a religion, then transplant surgery is a cult. Those dudes and dudettes get so amped for this stuff. Definitely not something you just dabble in, you either drink the Kool-Aid or stay away completely.

Truth.